The civil war over prescription opioids

Five years ago, Kathy S., a nurse, underwent spinal surgery. She has been in pain ever since. Still, she needs two more operations. She emailed me recently to say that her physician cannot prescribe her pain medicine because of government pressure against prescribing opioids. She asked me why she is being treated like a drug addict when all she wants is to function.  

Once, Kathy's story would have shocked me. Now, although her experience distresses me, I’m no longer surprised.

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Over the past 10 to 15 years, attitudes towards opioid use for pain have shifted dramatically. In the 1990s and early 2000s, pain relief was front and center on the newsstands and in medical literature. During that time, compassion for people in pain increased and permeated our culture and opioids became standard therapy for chronic pain, because few affordable and effective treatment alternatives existed.  

By the middle of the first decade of the 21st century, however, opioid-related casualties started to rise. When these deaths were attributed to increased opioid prescriptions for pain, tragic stories of ordinary citizens dying of opioid overdoses grabbed the headlines. Predictably, the United States public demanded a quick and easy solution.

Accordingly, many medical professionals changed their attitudes towards opioids. They replaced their compassion for people in pain with a concern for those being harmed by opioids. It was reasonable to be concerned about people who were harmed by opioids. However, it shouldn’t be a binary choice.

Reports about opioids routinely focused on the people who overdosed, but they ignored why opioids had been prescribed in the first place. People in chronic pain were mostly forgotten.

Negative cultural attitudes about opioids also seeped into fallacious conclusions and interpretations of scientific publications. For example, the Journal of the American Medical Association published an article last March titled, “Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial.” Subsequently, a firestorm of media articles appeared that misinterpreted the study and supported the anti-opioid narrative.  

The Washington Post joined the fray when its Editorial Board responded to the JAMA article with a column titled, “Another harsh truth about opioids: They’re not a better way to manage pain.” With this editorial, one more prestigious newspaper got the story wrong and hundreds of reports followed that continued to misrepresent the science about opioids. (I explained why these conclusions to the JAMA article are flawed in a Pain Medicine commentary).

A veritable war now exists between the needs of people in pain on one side and the popular crusade to limit — and even ban — opioid use on the other. With the zeal of moral crusaders, most clinicians and policymakers fall into one of the two camps.  

There almost seems to be a competition to see who can most egregiously demonize prescription opioids without sufficient scientific justification and without regard to the consequences. Here are two examples:

The Centers for Medicare and Medicaid Services (CMS) issued new opioid prescribing policies for Medicare drug plans that will take effect in January 2019. These policies were developed to curb over-prescribing, because some believe that overprescribing is the main contributing factor in opioid-related overdose deaths. However, in 2017, prescription opioids were involved in only about 19,000 of the 72,000 drug overdoses. Moreover, between 25 and 45 percent of overdose deaths may be suicides.

The CMS policies are based on the CDC opioid prescribing guideline, which itself is based on weak research. Nevertheless, governmental agencies are experiencing enormous pressure to do something about the opioid crisis while ignoring those in severe pain.

Even worse is the proposal by the Oregon Chronic Pain Task Force to drastically limit access to opioids for Medicaid patients who have been in severe pain. This proposal would force doctors to reduce dose levels, regardless of the patients' needs or the effect on their quality of life. The proposed changes are inconsistent with multiple guidelines, including the CDC Guideline for Prescribing Opioids for Chronic Pain and the new CMS opioid prescribing policies.

Medical professionals have started to voice their concern. The American Medical Association and Oregon Medical Association have said the Oregon Chronic Pain Task Force is proposing policies that could harm people in pain. Pain experts have sent Gov. Kate Brown (D-Ore.) a letter warning that the proposed changes are unsupported by science and could leave many patients more disabled and suffering needlessly.

The scientific literature, media reporting and policymakers are all responsible for analyzing two things without bias: the root causes of the opioid crisis and the consequences any corrective policy might have on people in pain.

Unfortunately, none of the governmental interventions have turned the tide on overdose deaths. In fact, evidence suggests that interventions, like the dose limits imposed by payers and legislators, have actually pushed abusers and patients to the street where the most dangerous drugs are found.  

We can’t solve the war over prescription opioids by failing to treat the millions of Americans who suffer from chronic pain. Unfortunately, by focusing only on the supply of opioids while ignoring those in pain, we will actually worsen a public health crisis that began when we, inspired by compassion, attempted to relieve pain.

Lynn R. Webster M.D., is a vice president of scientific affairs for PRA Health Sciences and consults with pharmaceutical companies. Webster is a former president of the American Academy of Pain Medicine and author of “The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us.” You can find him on Twitter: @LynnRWebsterMD.